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�, �'ers�? ; �ounty Health Department �
* _S��►age System � Improvements Permit
f Z-9z �H-215o NC fS7.5 �
Date: � This Permit Voic� Aftgr 5 Years �
Owner: M a� k �''7CGulld����, .. SR# /I85►
Subdivision Name: �� #
Lot Size: �� k Type of Dwelling: 1-� o use
Water Supply: Private: '�' Public: Community:
Bedrooms: �— Garbage Disposal
Basement � �A Basement Fixtures
INFORMATION CERTIFTTED BY
EIIV1TO11Iri0III� He�t}1 $pP.C1311St: owner or representative
��'S.
REPAIlt: REEV ATI
-------------------------
/2 et0
Size of Septic Tank: '7�'�' gallRns Size of Pump Tank:
Nitrification Line: S�OU' x 3� �"o� .,3 �x,al�oca, hcr�u
Depth of Stone: 12 inches /Z'�
Max Depth of Trenches: %�DD�ox; N,c�.e�� Z� ��
Altemative System: Conv. Pump LPPP� mp -.
Remarks: G'o •� t� e�� f�,r�/� L�ra,� •r4�r /� uav
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Date Well Approve�' Well should be 100 f� from any sewer system
BY Environmental Health Specialist
Date Sewa�e S stem Approved: � fl"" �- �—� lF
BY w� �� Environmental Health Specialist
CERTIFTCATE OF LETION ,..j
COIItCdCtOL: � � - /•�� �
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ r-�
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Sewage System location, installadon, and protection must meet state and local �
regulations. Septic tank should be pumped out every 3 to 5 yeazs and shall be maintained
by owner in such manner as not to create a public health hazard. Septic tank and
nitrification line must be inspected and approved by a member of the Person County �
Health Departrnent before any portion of the installation is covered and puf into use. If �
the site plans or intended use change this permit is subject to revocation. 1
(G.S. 130 A-335F) �
I.ocadon of sewage disposal sewage system sketched on back. �
(OVER)
a�i,'eE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
sup�ilies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located
at �later date. Note location of water supplies on�ad'�acen� �. �
rl
? _ Person County Health Department
-� � Well Permit
-2 � 2 This P�ermit Void After 5� Years
Owner.
Subdivision Name: '-��"
Drilling Contractor.
WELL CONSTRUCTION
Distance from Nearest Property Line�_ Distance fmm Source of
Pollution /a�
Total Depth: FG Yield: GPM Static Water Level Ft.
Water Bearing Zones: Depth Ft. Ft. FG Ft.
Casing: Depth: Fmm Q to��Ft. Diameter:��Inches
TYPE: Steel Galvanized Steel 3�
If Steel, does owner approve: Yes � No
Weight:�.,� Thickness: .j 843 Height Above Ground:_�� Inches
Drive Shoe: Yes_ L No
Were Problems Encountered in Setting the Casing? Yes No�_
If "yes" give reason• �
Grout: Type: Neat Sand/Cement Concrete
Annular Space Width � Inches /
Water in Annular Space: Yes No �
Method: Pumped Pressure Poured �
Depth: From c� co F� G
Materials Used: No. Bags Portland Cement Wei t of 1 bag�lbs.
If mixture (sand, gravel, cuttings) - Ratio:� to�_
ID Plates: Yes�_ No
4 x 4 slab Yes No ,
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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND THAT �
THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH REGULATIONS SET
FORTH BY THE PERSON COUNTY HEA�I,TH DEPARTMENT. �
111 n ► , „n � ---�
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Date Issu'eW�
t1.Z,�iZ
Sanitarian's Signature Date Completed
Sketch well location on reverse side.
1`.IOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water
supplies, etc. Note special problems existing on lot. Write in measurements ir� or�ier that installations may be
located at later date. Note location of water supplies on adjacent lots. ,� �,�„-U.�. �